The articles chosen to be evaluated, compared, analyse and reflected upon are

Nursing models and Contemporary Nursing: their development, uses and limitations, Nursing models and contemporary nursing: can they raise standards of care and lastly Safeguarding vulnerable adults

. The reasons for selecting the topics above are based on exposure to the subject matter in university and familiarity with the safeguarding vulnerable adults during the many years spent working as a Health Care support worker within the community. Most of all, the ultimate reason choosing these topics is sheer interest in finding out how effective the usage of these integral topics can improve holistic nursing practice and give the service user or patients a better experience. Supporting evidence for this report were sourced from various mediums i.e. Through the internet and from credible websites such as the Royal College of Nursing, Nursing Times and article catalogue banks such as CINHL and Medline.

Murphy, F; Williams, A and Pridmore, J (2010) Nursing models and contemporary nursing 1: their development, uses and limitation.



Nursing Times



15 June, 2010, vol 106, No 23pp18-20.

Pridmore J et al (2010 Nursing models and contemporary nursing 2: can they raise standards of care?



Nursing Times



21st June, 2010 Vol 106, Number 24.

These articles are suitable for the education, training and informing Healthcare Professionals about the prominence of their field. The articles are presented in a good and coherent fashion, this makes the reading experience enjoyable. The two-part series analyses the worth of nursing models and deliberates whether the essential concepts, principles and ethics about nursing in these models are pertinent to contemporary procedures. This first article provided an outline of nursing models; how and why they were established; and some poignant criticisms. The second article examined the models in the framework of modern nursing practice, with specific attention placed on current initiatives intended to reform nursing and to improve the standards of care.

The authors of these articles are experienced and seasoned professionals in their fields of expertise. Fiona Murphy, for example, is a nurse who has held clinical positions as a Sister, staff nurse and clinical teacher in acute hospitals nursing all over the United Kingdom. She has taught and lectured at the University of Swansea since 1992 and worked on a variety of undergraduate and post graduate nursing and midwifery programmes. (Dockerty, 2013) Julia Pridmore, is also a Nurse Lecturer and programme manager for BSc (Hons) Health and Social Care at the University of Swansea. Julia has been a practicing nurse since the 1980s. She specialises on quality improvement, governance and patient safety (Pridmore, 2010). Their experience in practice and teaching combined, validates their knowledge of the subject and also authenticate the issues raised in the articles.

The authors, gave a very insightful historical background about the technological boom which triggered the development of nursing models in the early 1960’s in the United States, but it failed to examine the reasons why it took more than a decade for the same to be adopted in the United Kingdom. One could be identified with the difficulty in acclimatizing to an entirely different concept, but the impediment to change as described by (Kenny 1993) ‘reflecting on the approach and attitude towards change and the bureaucratic environment of the NHS, also questioned if models really stood any chance at all’. This statement speaks a lot of volumes but completely void of proofs or facts. The National Health Service have been a driver for change and modification since inception. The Nurses Act of 1949, for example was established to modernise the role of nursing by providing the catalyst for modification to nursing education and training, 1940s and 50s saw nurses uniform begin to become more standardised, in 1955 the nursing auxiliary or nursing assistant role achieved formal recognition and Enoch Powell’s Hospital Plan recommended that teaching hospitals should act as district general hospitals and that student should be taught where patients required treatment in 1962. Prior to the adaptation of models in the United States the National Health Service was in its twentieth year of reformation, one can conclude Kenny 1993 quote on attitude to change and bureaucracy within the environment of the NHS is possibly a hypothesis.

Secondly, there were numerous complications in developing the models, the smallest of which was an absence of a definition of nursing. This led to Henderson’s description being regularly quoted, and it shaped the foundation of vast majority of deliberations. There were also calls to go back to the ideas of Florence Nightingale. Henderson defines both the independent and the co-dependent features of nursing practice, and stipulates the affiliation between nursing and medicine. This difference between independent and co-dependent practice is vital to appreciating the intricacy of nursing and its specific influence inside the multi-disciplinary teams within a health care setting. Nightingale’s emphasis on the advancement of health and healing as separate from the treatment of disease, and the harmony of the individual, well-being and the atmosphere, remain essential to contemporary explanations of nursing. Both philosophies and ideas resounds clearly in the models, a good indication of the advancements and strides made since the days of Florence Nightingale. In hind sight, going back on the ideas to reflect the idle of Florence Nightingale would be a complete retrogression, but rather using models as a framework to guide and reform the delivery of care and will directly improve the experience of the patient thereby affirming the professional outlook of the nurse within the healthcare setting.

Betts V; Marks-Maran, D and Morris-Thompson, T (2014) Safeguarding vulnerable adults.



Nursing Standard.



28, 38 P37-41.

This article is suitable for the teaching, preparation and informing Healthcare Professionals about the importance and efficacy of safeguarding the vulnerable within the confines of the hospital and beyond. The article is presented in clear and comprehensible manner, this makes the reading experience very pleasant. The article examines more or less the matters surrounding safeguarding vulnerable adults, it reviews some of the correlated legislation and literature, and outlines the responsibilities of authorities or those who care for these patient groups. The article reveals how one hospital that is specialised in caring for individuals with early-onset dementia, Huntingdon’s disease and alcohol-related brain damage who need supplementary care, has provided staff with fitting evidence-based facts about safeguarding adults.

The authors of this article are knowledgeable and experienced authorities in their fields. Virginia Betts Previously a staff nurse at Forest Hospital, Nottingham and presently health visitor student at Derby University, Diane Marks-Maran is an honorary professor of nursing at Kingston University, London and St George’s, University of London, lastly, Trish Morris-Thompson director of quality and clinical governance at Barchester Healthcare, London. Their involvement in practice and education authenticates their understanding of the theme being examined i.e. Safeguarding Vulnerable Adults and also substantiate the issues raised in the article.

This is an evidence based literature which draws lessons and references from current events in Winterbourne View Hospital and Mid Staffordshire NHS Foundation Trust. This article failed to explore in to details the avenues of trainings, retraining, and refresher courses to ensure staff and healthcare professional are constantly reminded of the importance of safeguarding the vulnerable. Although, Nesbit’s warning that no structure or system of safeguarding would be able to pledge with certainty that abuse would certainly not transpire (Nesbit 2013) is completely a valid argument. It also very important to raise, continuous trainings and adequate reminders are the key to keeping this all important subject current and relevant to the healthcare professional. With the view of avoiding a repeat of the happening of Winterbourne View and Mid Staffordshire NHS Foundation Trust, the issue of training, retraining and refresher courses cannot be over emphasised.

Research and policy guidance advocates compulsory trainings for care home proprietors and executives in view of safeguarding responsibilities. ‘No secrets’ (DH/Home Office, 2000) also mentioned that all organisations must train all employees and volunteers at all levels of hierarchy within their agencies, organisation or companies, with respect to their responsibilities in the adult safeguarding procedures and processes. Kalaga and Kingston (2007) referred to the commendations of the enquiry into the delivery of services for individuals with learning difficulties at the Cornwall Partnership NHS Trust which specified that the Trust must: ‘as a priority, develop a programme of training, supervision and support for all staff which helps them deliver care in accordance with the principles of the Valuing People strategy’. (CSCI/Healthcare Commission, 2006, p 69) Organisations must ensure a safe environment in which all employees are trained in safeguarding, and authorities such as managers, supervisors and even team leaders be responsible for systematic official checks of the organisation’s safeguarding procedures, policies, processes and practices.

In essence, the evidence presented for Forest Hospital in Nottingham inaugurated in 2013 to deliver expert care for individuals with early-onset dementia, Huntingdon’s disease and alcohol-related brain injury is exemplary, the institution have gone through a great deal of meticulous planning to encourage the retention of information and training pertaining to safeguarding. All employees new to the establishment obtain an information guide and commence e-learning induction sections on safeguarding vulnerable adults, followed by team deliberations on some of the subjects raised on the materials and guides given, and the sections. Throughout the segments and group studies, employees are familiarised with and well-versed on safeguarding vulnerable adults.

Responses, feedbacks and questions are given in writing and verbally from employees and shown that employees who had never worked in care homes or anything similar to care found the training on safeguarding adults educational and easy to comprehend. Employees identified that they valued the chance to utilize the learning tools on safeguarding adults in group discussions. They also mentioned that it was extremely beneficial having a written document to which references could be made when needed. This method of training is entirely innovative and worthy of emulation by every institution and NHS Trusts.

The only criticism about the training method in Forest Hospital is the fact the authors provided no detail concerning its frequency. It is vital to note, some of the issues in Mid Staffordshire NHS Trust according to the HealthCare Commission was not due to lack of training but rather lack of adequate training. As a firm believer in learning, unlearn and relearning, training a healthcare professional once or maybe twice in his or her career is not enough. Safeguarding just like manual handling require expiration in its certification. This will enable a continuous assessment of employee knowledge and practical skills with respect to safeguarding thereby delivering exceptional service to the patient.

In retrospect, one could say the article on Safeguarding focused mainly on physical abuse by so doing leaving a lot of safeguarding issues unaddressed. Abuse may be physical, psychological, financial or material, sexual, discriminatory, or an act of neglect or an omission to act. For example the involvement of exploitation and mistreatment is likely to have a major impact on a person’s health and wellbeing. By the very nature exploitation and utter abuse of power by one person over another has an enormous impact on a person’s independence and most times depresses their individualities, which are a breach of the rudimentary ethos of the Healthcare profession. Neglect on the other hand, was not mentioned, but it can stop an individual who is reliant on others for their fundamental necessities, exercising choice and control over the basic needs of life and can cause embarrassment, humiliation and loss of self-respect. All vulnerable adults have the right to be assisted to make their own choices and to give or deny consent on whatever they please, be it activities or even services. Consent is a strong sign of a readiness to partake in an activity or to receive a service. It may be gestured, verbal agreement, or in writing. No individual can or should give, or refuse, consent on behalf of a different adult except exceptional provision for specific purposes have been made and it generally by law.

The main struggle dealing with abuse of vulnerable adults is knowing that it exists, because it’s multifaceted nature. DeHart et al (2009) cross-examined nursing home employees, policy makers and health care professionals to detect training needs of employees. They discovered that those at risk of abuse were residents who are silent, confused and incapable to communicating or those who have few visitors, as well as those who are non-compliant or with challenging behaviours. They proposed that one of the employees capabilities must be the skill ‘to identify residents’ vulnerabilities that increase the risk of their being mistreated’.

A key United Kingdom survey of more than 2000 individuals of age 66 and over living in private accommodations and households discovered a variety of risk factors, precise to the category of abuse: The risk factors for neglect encompassed being female from 85 years of age, in bad health or depression and the prospect of being in receipt of, or in touch with, services. The risk of financial abuse amplified for individual living alone, in receipt of services, in bad or very bad health, older men, and women who were divorced or separated, or lonely. The risk of relational abuse (physical, psychological and sexual abuse combined) was greater in women aged 66–74 (O’Keefe et al, 2007). O’Dowd (2007), in reporting on the above research, recommended the discoveries on risk factors, citing that it should be used by local authorities to observe and act on abuse by directing assistance where it is wanted most. Appointing full-time safeguarding leads or introducing training for all staff i.e. relevant training for all new staff, from auxiliary to consultant level, as part of its induction programme, and another where training is consolidated at handover times to keep it refreshed and serve as a constant reminder at all time.

On the Aspect of Nursing Models, Nurses do require a theoretical framework to serve as a guide and support. This is predominantly so now that we confronted economic, demographic and communal variation that will possibly “value the nurse out of the market”. Devoid of using theory to define what nursing is and does, it would extremely stress-free to demote the role of the Nurse to nothing else but just elementary tasks, when nursing is as a matter of fact, a multifaceted, vibrant and thought-provoking role demanding the mixture of understanding , knowledge, skills, familiarity and theory. The usage of nursing theories such as models assist nurses to make the difference amongst the contributions of the medical, nursing and other healthcare professionals and establish the worth of the nurse.

Nurses are acquainted with problem-solving methods such as ASPIRE (Assessment, Systematic nursing diagnosis, Planning, Implementation, Recheck and Evaluation). However, methods like this guides in care planning, they are short on detail on how to do it. For example, a problem-solving procedure is less likely to outline questions needs asking in the course of an assessment or the interventions to be made. Nursing model can drastically improve the methods of assessment and deliver better care. (Barrett et al, 2012)

Models can play a variety of roles in the career of the nurse. Take for example, the newly qualified nurse, a model will be a very import framework for the care planning process. A proficient nurse will have the ability cultivate their own diverse model, grounded on the fundamentals of different theories that fits their methodology and framework of care.

In conclusion, nursing continue to offer challenging roles in dynamic, evolving healthcare environments. However, the competitive workforce means that in order to first attract and then retain nurses, Authorities in Healthcare needs to ensure that practices are contemporary and innovative. It is also important to recognise that Nurses are part of a broader healthcare team and it is appropriate that to consider and assess the best way to work with other healthcare providers to provide quality patient care now and into the future.

Safeguarding adults is everybody’s business. Statutory agencies and all who work with Vulnerable Adults have the responsibility to safeguard the wellbeing and safety of Vulnerable Adults in different ways. “Safeguarding” when viewed in its wider sense of promoting the safety, wellbeing and opportunities of adults forms part of core business for all statutory agencies, for example, ensuring health and patient safety is the NHS responsibility, promoting independence and wellbeing is the responsibility of Adult Social Care, and protecting people from harm is the responsibility of the Police. For all professionals, “safeguarding” in its wider sense is part and parcel of everyday working life. However, it also refers to a very specific area of work- the reactive inter-agency response to protect Vulnerable Adults who are at risk of significant harm through abuse by another person or persons. Empowerment and choice need to be at the core of safeguarding policy and practice; this means working to enable adults at risk to recognise and protect themselves from abuse. It also means taking a risk enabling approach within services and ensuring that people who use services have genuine choice both of and within services.

Bibliography

Dockerty, R. (2013). Swansea nurse lecturer writes ‘Major Works’ book.

Swansea University

, Swansea nurse lecturer writes ‘Major Works’ book. [Online]. Available at:

http://www.swansea.ac.uk/humanandhealthsciences/news-and-events/latest-news/swanseanurselecturerwritesmajorworksbook.php

[Accessed: 6 November 2014].

Pridmore, J. (2010). Julia Pridmore.

Nursing Times

, Julia Pridmore | Nursing Times. [Online]. Available at:

http://www.nursingtimes.net/julia-

/148596.publicprofile [Accessed: 6 November 2014].

Choi, N.G. and Mayer, J. (2000) ‘Elder abuse, neglect, and exploitation – risk factors and prevention strategies’, Journal of Gerontological Social Work, vol 33, no 2, pp 5–26.

DeHart, D., Webb, J. and Cornman, C. (2009) ‘Prevention of elder mistreatment in nursing homes: competencies for direct-care staff’, Journal of Elder Abuse & Neglect, vol 21, no 4, pp 360–78.

Department of Health (2010) Prioritising need in the context of Putting People First: a whole system approach to eligibility for social care – guidance on eligibility criteria for adult social care, England 2010, London: Department of Health.

For this assignment I have been asked to look at the care I have seen and been involved in giving to a woman with a high risk pregnancy. I intend to identify how my practice could be developed to meet the similar needs of women in the future. To do this I am going to use a reflective approach. I am going to look at the normal anatomy and physiology and analyse the patho-physiology in relation to high risk pregnancy and birth.

For most women, their midwife is their first point of contact so they have a crucial role to play in identifying any risks. Included in their extensive role is facilitating pregnancy and childbirth as a positive and fulfilling experience. This is most fundamental for those women whose childbearing experience has been categorised as high risk (Page, 2006).

A pregnancy is classed as high risk if there are any factors that may adversely affect the fetal or maternal outcome. Risk factors must be identified as early as possible to increase the chances of an improved outcome (Queenan et al, 2007).

When a woman is booked for her maternity care, her medical and obstetric history is taken to ascertain whether she would be suitable for midwifery led care (low risk) or consultant or obstetric led care (high risk). A woman can change from either group during her pregnancy. For example, she may start her care as low risk but then something may happen or a condition may develop so she may therefore require consultant input into her care.

Factors which could mean a woman has a high risk pregnancy include epilepsy, diabetes, cardiac problems, multiple pregnancy, hypertension, obesity and previous obstetric complications, i.e. caesarean section, previous haemorrhage (whether that be antepartum, intrapartum or postpartum), recurrent miscarriages or previous intra-uterine death.

Using Gibbs’ (1988) reflective cycle, I am going to discuss a woman I recently cared for whilst working on Central Delivery Suite, whose pregnancy had been assessed as high risk. This was due to her having had a previous emergency caesarean section and a previous ventouse delivery.

In accordance with The Code (NMC, 2008) I have changed all names mentioned to respect their confidentiality.

Description:

Laura, aged 39 years old, was 39+1 weeks pregnant, gravida three, para two. As just mentioned, her obstetric history meant she would see an obstetric consultant during her pregnancy. As Laura was planning on having a vaginal birth after caesarean section (VBAC) this increased her risk. It was also apparent she had tested positive for Group B Streptococcus (GBS) in both her previous pregnancies. Laura had gone into spontaneous labour. Laura and her partner had both requested antibiotics to be started as soon as possible due to the previous GBS. This was not something my mentor could agree to as Laura had not tested positive for it at any point during this pregnancy.

However, due to Laura’s admission temperature reading being 38.1°C and in view of the previous two pregnancies testing positive for GBS, it was decided by the obstetric consultant on duty that she would receive antibiotics during labour. We confirmed she was in established labour by performing a vaginal examination, with consent, and finding the cervix was 4-5 cms dilated, partially effaced and membranes were felt intact. After Laura was cannulated, the antibiotic Benzylpenicillin (Penicillin G) 3g was administered intravenously. Then at four-hourly intervals she was given 1.5g until delivery. Due to Laura’s high risk status a cardiotocograph (CTG) was commenced to keep a trace on the fetal heart rate and the uterine contractions.

Laura laboured for approximately 6 hours in total, and went on to have a normal vaginal delivery of a healthy baby boy.

Postnatally, Laura’s observations were taken and baby observations were also taken six hourly and observed for a minimum of twelve hours in accordance with Local Trust Guidelines (Local Trust, 2005).

Feelings:

This event particularly sticks in my mind due to my own curiosity about Group B Streptococcus. When Laura was showing a temperature of 38.1°C, I recognised this was out of the normal range so I informed my mentor. I knew a high temperature could indicate a sign of infection so it was important I made my mentor aware. I felt calm at the time and knew my mentor and the obstetric consultant had the matter under control. My mentor made me feel included in the situation and explained fully what she was doing and when. She went through the process of preparing the drugs and the IV line with me.

I was very happy with the outcome of the situation. At the end of the day, we all wanted a normal, natural delivery of a healthy baby and that was achieved.

Evaluation:

The ultimate goal of this situation was a healthy mother and baby, which was successfully achieved. I am glad the consultant made the decision that Laura would be started on antibiotics as I was aware of how anxious she was.

Analysis:

The final outcome was Laura had a healthy baby with no signs of GBS disease.

Contributing factors to this were how I relayed important information to my mentor and how the obstetric consultant made the right choice offering Laura antibiotics, even though she had not tested positive for GBS in this pregnancy.

I believe Laura should have been offered a test for GBS to confirm if it was present in this pregnancy or not. She was very anxious about the situation so I feel this would have at least helped put her mind at rest knowing either way. Her and her partner had come to CDS demanding antibiotics as a precaution anyway, and luckily for her, her high temperature meant she received them. Had she not had the high temperature that decision would have been down to the consultant.

Conclusion:

I learnt from this experience the correct drugs to be given in labour, and the quantities and times stages they should be given. I also learnt the drug to be given if the woman is allergic to the primary choice drug. Plus, from using this topic as my high risk assignment, the further reading I have undertaken has also taught me a lot.

Action Plan:

If the situation happened again, I would feel more confident in my knowledge of explaining to the woman and her family why we would advise her to have the antibiotics. In this particular situation, Laura knew a lot about GBS due to her previous pregnancies being tested for it and she was then subsequently treated during the labours. However, if a woman I was caring for had little knowledge of GBS, I feel I could explain it.

Laura was classified as high risk due to her previous obstetric history. However, I am going to concentrate on the Group B streptococcus (GBS) she was concerned she had, after having it in both previous pregnancies. I also have a personal interest around GBS as this was something I tested positive for during my pregnancy and I did not really understand what it was or the complications of it. I was screened routinely as I was living in Spain at the time. Laura was only aware of her GBS, in her previous pregnancies, due to routine screening in Germany. She had not been screened here in the UK for GBS in this pregnancy, due to the uncertainty of clinical evidence and cost effectiveness of the routine screening (NICE, 2003). As mentioned in my reflection, this was something Laura was concerned about and requested she receive antibiotics during her labour as a precaution.

Group B streptococcus is a common type of streptococcus bacterium. Approximately a third of men and women are ‘carriers’ of GBS in their intestines and a quarter of women carry it in their vagina. Most people are unaware they are carriers as it can be difficult to detect and does not cause any symptoms. Carrying it is perfectly normal as it is one of many different bacteria’s that live within our bodies.

Problems can arise when GBS is transmitted to the fetus. This could happen if the membranes rupture, during labour or the delivery. The fetus could come into contact with GBS if the bacterium travels upwards from the woman’s vagina and into the uterus due to the membranes not being there to protect the fetus. If there are prolonged rupture of membranes there is increased risk of transmission due to more time for the micro-organisms to be transported from the vagina into the cervix, and then to the uterus. According to the Group B Strep Association there is also evidence that GBS may cross intact membranes to expose the fetus whilst it is still in the womb. This could therefore cause preterm births, stillbirths or miscarriages. The fetus could also be exposed while passing through the birth canal. A preterm infant would be more susceptible as their lesser-developed bodies and immune systems are more vulnerable to GBS infection than older infants. The fetus could become infected if they swallow or inhale the bacteria (GBSA, 2011). If the fetus acquires GBS in utero this is known as early onset (Chapman, 2003).

GBS can also be found on the hands and in the respiratory tract of a colonised person. So once a baby is born, GBS could be passed on to it from the hands. This is why, especially within the first 3 months of a baby’s life, it is so important for anyone who comes into contact with a baby, washes and dries their hands thoroughly. If the baby was to develop the disease from repeated exposure, this is called late onset (Chapman, 2003).

In Laura’s case, we were concerned about in utero transmission which could cause early onset GBS disease. This gave us the option for the administration of prophylactic antibiotics during labour, and at least two hours before delivery, which has been shown to reduce the frequency of neonatal GBS infection (Local Trust Guideline, 2009). Antibiotics given during labour can be very effective at preventing this transmission.

A guideline written by The Royal College of Obstetricians and Gynaecologists (RCOG, 2003) state a woman should be offered intrapartum antibiotic prophylaxis if they have the following risk factors:

â- previous baby affected by GBS

â- GBS bacteriuria detected during the current pregnancy

â- preterm labour (less than 37 completed weeks of pregnancy)

â- prolonged rupture of the membranes (more than 18 hours before delivery)

â- fever in labour (a temperature of more than 37.8°C)

Although Laura only had one of the above risk factors, she was offered the antibiotics at the discretion of the consultant.

Women must also be reminded of the risks with taking antibiotics and be given all the information so they can make an informed choice. The antibiotics a woman receives will also depend if she has any allergies to medication. The recommended antibiotic for those allergic to penicillin is clindamycin, 900mg administered intravenously, from onset of labour and every 8 hours until delivery (GBSS, 2007, & Local Trust Guideline, 2005).

During my placement on the Neonatal Unit, I also cared for a baby that had to be admitted for antibiotics as its mother had tested positive for GBS during her pregnancy. She was unable to receive antibiotics as the the delivery was so fast and there was not enough time. Therefore the baby was admitted to the Neonatal Unit so he could receive antibiotics. Blood cultures from the baby were obtained and he was treated with penicillin until the culture results were available. This enhanced the importance of the woman receiving the prophylactic antibiotics during labour.

In any high risk situation it is vital that maternal and fetal well being is monitored.

As Laura was high risk she was placed on continuous cardiotocograph (CTG) monitoring.

This gave us a recording and trace of the fetal heart rate so we could indentify any deviation from the norm, in comparison with the baseline for that baby. The primary aim of the CTG is to identify a fetus that may be hypoxic so additional assessments of fetal well-being can be used (i.e. fetal blood sampling) or the fetus being delivered by an instrumental vaginal birth or caesarean section. The use of this kind of technology is justified in being able to save the life a fetus that is shown to be in distress.

The CTG detects the fetal heart rate (FHR) and the uterine activity (toco) simultaneously and displays it in the form of graph. It is important to check the maternal pulse at the same time as applying the CTG, to ensure the machine is recording the fetal heart rate, and not the mothers. The modern machines we use at my Trust have a maternal pulse sensor which the mother applies to her finger, which then records the maternal pulse rate on the graph that is printed out.

The continuous electronic monitoring using the CTG is vital to get a contemporaneous recording of the fetal heart rate. It will give us the baseline heart rate (usually between 110-160 beats per minute), accelerations (momentary increases in the fetal heart rate) and decelerations (momentary decreases in the fetal heart rate). Some aspects of labour will cause natural alterations in the FHR patterns. For example, the pattern will be different when the fetus is asleep or awake. External factors, like uterine contractions and maternal movement can cause the FHR to change. The FHR can also be affected by opiate based painkillers, like pethidine. Some of these changes are quite subtle and can only be detected by continuous CTG e.g. baseline variability, temporal shape of decelerations.

To be a competent midwife, it is imperative I have knowledge on how to interpret the recorded traces of a CTG. I have seen many CTG traces whilst on my hospital placement due to the high number of high risk women my Trust cares for. However, I still feel I am learning new things every time I see one, as everyone is different. I can distinguish between baseline tachycardia (where the fetal heart rate baseline rises above 160 beats per minute) and baseline bradycardia (the opposite, where the fetal heart rate baseline goes below 110 beats per minute) (Mukherjee, 2007).

Baseline tachycardia could be physiological if the trace is from a preterm fetus due to immaturity or secondary to maternal pyrexia or dehydration. It could also be a sign of fetal hypoxia. The fetus would try to increase the cardiac output mainly by increasing the heart rate to supply vital organs with oxygen and nutrients.

Baseline bradycardia could be physiological if the trace is from a post-term fetus or possibly a large fetus, provided there are also accelerations present and there baseline variability is above the normal range (>5 beats per minute). If it is just baseline bradycardia with no other normal or reassuring factors, this would need immediate action.

Another form of technology used within Laura’s pregnancy was screening. When she was initially booked for her antenatal care, her blood and urine would have be sent for screening, after she consented to this. She would also have attended ultrasound scans which are also a form of screening. This is something that is offered to all pregnant women and regardless of their risk status, it is used in both low and high risk pregnancies. It is a process which has been developed, which was not done previously due to lack of knowledge and technology. The standard screening during the antenatal period is urine; to check for any sign of infection, and blood; to check the woman’s blood group, her rhesus status, her iron levels, if she is immune to rubella, and to check for hepatitis B, syphilis and HIV (NHS Choices, 2011).

In line with the National Institute for Clinical Excellence (2003) pregnant women should be offered evidence based information and support to enable them to make informed decisions regarding their care. This means women should be informed of all screening tests available to them. I believe this should include information about screening which is not necessarily available within the NHS but could be carried out privately, for example, GBS screening.

There are arguments for and against introducing routine screening for GBS in the UK. Plumb, Holwell and Clayton (2007) argue that in the UK, GBS prevention is inadequate. They believe the NHS should offer testing for GBS in late pregnancy, thus giving women the opportunity to establish whether their baby is at higher risk of developing the GBS infection.

My current Trust guideline (2005) state there is not enough evidence for it at this time.

GBS awareness campaigners, Group B Strep Support, are pushing for routine testing to be introduced in the UK (Prince, 2011). According to GBSS, Western countries that routinely test, have a lower incidence of infection in new born babies, where as cases in the UK are on the rise. Even since the introduction of the Royal College of Obstetrics and Gynaecologist’s guideline for preventing GBS infection in newborns, in 2003, there has not been a decrease in either the number or the incidence of GBS infections in babies (GBSS, 2007).

The table below shows the how the GBS infection in babies has increased throughout England, Wales and Northern Ireland.

Year report published

Number

All cases

(babies 0-90 days old

Incidence per 1000 live births

Number

Early onset (babies 0-6 days old) Incidence per 1000 live births

Number

Late onset (babies 7-90 days old) Incidence per 1000 live births

Number

2003/3004

311

0.48

207

0.32

104

0.16

0.48

2006/2007

409

0.61

248

0.37

161

0.24

0.61

2007/2008

421

0.61

258

0.37

163

0.24

0.61

2008/2009

470

0.66

279

0.39

191

0.27

0.66

(data published by the Health Protection Agency taken from www.gbss.org.uk/filepool/GBS_Infections_on_the_Increase.doc)

Table 1 Number and rate (per 1000 live births) of group B streptococcal bacteraemia reports in infant’s 0‐90 days old in England, Wales and Northern Ireland: 2003-2009.

The overall number of GBS infections within adults is also reported to have increased by more than 72% from 2001 to 2008:

(data published by the Health Protection Agency

taken from www.gbss.org.uk/filepool/GBS_Infections_on_the_Increase.doc)

Table 2 Number of GBS infections in both males and females

within England, Wales and Northern Ireland: 2001-2008.

A better indication of the rise in GBS infections would be taken from women only, who are 35-37 weeks pregnant. I believe this would give more of an insight into pregnancy GBS infection rates.

While the evidence states the increase in rates, I could not find any reasons for the increases. Some factors I believe may contribute to the rise include the lack of personal hygiene, modern living or even due to lifestyle. For example, many years ago clothing and underwear used to be boiled when washing but now people may be washing their clothes on a 40°C wash and this may not be enough to kill all the bacteria.

It may not be due to any of these factors; it may just be we have a better awareness of GBS now then what we did years ago. With the constant improvement of technology, we will also be finding out new things.

Although the internet is not a form of technology we use within midwifery, it is certainly a form of technology we definitely need to be aware of. Within the last ten years or so, the internet has become increasingly popular. This means the general public can find about anything, more importantly medical information they may not have been able to access before. Therefore, we need to be aware of those women that we care for, that may have either some basic knowledge or an in-depth knowledge of a medical issue, for instance GBS. The NHS even has a website called NHS Choices (www.nhs.uk) which people can access to check symptoms and research illnesses and also pregnancy. I think this is mainly a good thing, although women may read so much into something they find online and it may make them more anxious or worried. It should not replace the direct contact with their midwife.

The Nursing and Midwifery Council (NMC, 2008), state we should be delivering care based on the best available evidence. By reading the research I have found to write this assignment I am adhering to The Code by giving women evidence based advice. I may not be able to radically change my operational practice but I will definitely be more aware of what to look for and how to manage the situation. I will also ensure I am aware of those women who may have a more in-depth knowledge about GBS and understand their anxieties.

From writing this assignment I have identified the risks of GBS, who the risks affect and to what degree it could affect them. I feel I would be able to recognise the signs and be aware of the treatment and management. I have acknowledged the main technology used is for the screening of GBS within the laboratory investigation systems and believe this should be carried out routinely within the UK.

Final Word Count: 3,361